Little Gaynes Rest Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question requires improvement. At this assessment, the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion.

The registered manager maintained an open-door policy, encouraging people, relatives, and staff to share any concerns or suggestions. This openness helped the service to run effectively and responsively.

People, relatives and staff felt the management team was approachable and were able to discuss anything with them. Staff said the registered manager was supportive. A person told us, “The manager is good.” A relative said, “I am very happy with the home.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care.

The management team created a welcoming environment where people, their families, and staff felt comfortable sharing their thoughts and feelings.

People and their relatives told us that the management team were accessible. People said they were happy with the staff and the support provided. Relatives told us they knew how to raise any concerns with the service and they were always kept up to date with what was happening with their family members.

Staff were provided with clear information and guidance covering various aspects of their roles and responsibilities. They told us they felt valued and supported by the management team and were included in discussions and decisions about the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy in place, and this gave guidance to staff on how they could raise concerns about any unsafe practice. A whistle blower is a person who exposes any kind of information or activity that is deemed illegal, unethical, or not correct within an organisation. Records showed and staff confirmed they had undertaken training to support their knowledge and understanding of how to keep people safe.

Staff knew of the whistleblowing policy and how to raise concerns about any unsafe practice.

A person said, “I am safe here.” A relative told us, “We don’t have any concerns.”

The provider fostered a positive organisational culture in which staff felt empowered to speak up, confident that they would be supported and that their views would be listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider ensured staff who worked for them had an equal opportunity and were not treated differently or discriminated against because of their characteristics. Staff had equal opportunity to fulfil their potential.

The registered manager kept staff informed about things happening in the service. There were regular staff meetings where they had opportunities to discuss any issues or concerns, they might have.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support.

At the last inspection, we found systems to assess, monitor and improve the quality of the service were not always been effective. Care plan audits were carried out, but these had failed to identify that care plans did not cover needs related to equality and diversity in a comprehensive way. Monitoring systems had also failed to identify that conditions set in DoLS authorisations had not always been complied with.

During this assessment, we found improvements had been made around the concerns we identified at our previous inspection.

The provider had systems in place to assess, monitor and improve the quality and safety of the services provided. There were audits carried out of care records, people’s support plans, staff training, infection control and health and safety. If shortfalls were identified, appropriate actions were taken, for example, asking staff to complete refresher training if they were not up to date. We also found effective systems were in place to monitor and ensure conditions set in DoLS authorisations were complied with.

The registered manager understood what their roles and responsibilities were. They kept us informed about certain events, so that we could see what actions they had taken or if we needed to follow up on any information, they had sent us.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The registered manager worked closely with other health and social care professionals to ensure people received the care and support they needed. This helped to ensure people’s needs were met.

People’s healthcare needs were reviewed as required and managed to ensure that they received the care and support to keep them in good health. For example, we saw staff contacted the GP to seek advice as for a person who was not well and the person was prescribed a course of antibiotics. People’s needs were monitored and referrals were made to the relevant health care professionals accordingly.

People had the contact details of their doctor recorded in their care plans. This helped to ensure staff could also contact them if they had concerns about a person's health.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had systems in place to ensure that learning happened when things could be improved, for example, following any accident or incident.

The provider also continually sought feedback from people, relatives and staff about the service. These were gained through the use of satisfaction surveys which were completed on a yearly basis. We saw comments from the recent completed satisfaction surveys were positive. The provider analysed the feedback received and this helped to improve the quality of service provided. They acknowledged and addressed any areas of improvement if needed.